Introducing medical students to paediatric pain management.
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Analgesia↗
Biomedical subjects
Ira Todd Cohen
Publications and source records attributed to Ira Todd Cohen.
Caudal block complication in a patient with trisomy 13.
In this report we describe a complication of a caudal block in a 4-year-old child with trisomy 13. The patient's history was remarkable for microcephaly, developmental delay, seizures, apnea, and prolonged emergence times. Induction of anesthesia and tracheal intubation were uneventful. A caudal block was aborted after positive aspiration of cerebrospinal fluid. A radiogram suggestive of spinal dysraphism, found on subsequent review, was confirmed by a magnetic resonance imaging scan consistent with tethered cord and dural ectasia. Congenital abnormalities associated with trisomy 13 and cutaneous signs suggestive of spinal abnormalities are reviewed. Avoidance of neuraxial regional anesthesia in these patients is recommended.
Abnormalities, Multiple↗
Repeat episodes of severe muscle rigidity in a child receiving sevoflurane.
We report on a patient who developed two episodes of severe muscle rigidity, increased endtidal CO2 and increased creatine phosphate kinase associated with sevoflurane anesthesia. Dysrhythmias and hyperthermia were not observed and dantrolene was not administered. Genetic testing for the 17 known mutations associated with malignant hyperthermia (MH) was negative. Although we cannot rule out MH or other neuromuscular diseases we suggest that this rare event may be a direct effect of sevoflurane.
Abnormalities, Multiple↗
Peer review interrater concordance of scientific abstracts: a study of anesthesiology subspecialty and component societies.
Abstracts presented at anesthesiology subspeciality and component society meetings are chosen by peer review. We assessed this process by examining selection criteria and determining interrater concordance. For the societies studied, the level of reviewer agreement ranged from poor to moderate, i.e., slightly better than by chance alone. We hypothesize that having clearer evaluation criteria, scoring systems with interval scales, and assessment based on quality can strengthen the peer review process.
Analysis of Variance↗
Ondansetron oral disintegrating tablets: acceptability and efficacy in children undergoing adenotonsillectomy.
Postoperative nausea and vomiting (PONV), a major complication in children, is responsive to IV and oral ondansetron. Because these routes are not always available, we studied the acceptability and efficacy of ondansetron oral disintegrating tablets (ODT). In this double-blind, randomized, placebo-controlled study, 62 patients undergoing adenotonsillectomy, aged 5 to 11 years, preoperatively received ODT (4 mg) or placebo. Patients assessed the medication for taste and sensation. Anesthesia was induced with sevoflurane, maintained with desflurane, and supplemented with fentanyl 2.5 microg/kg and dexamethasone 0.5 mg/kg (maximum dose, 12 mg). An observer blinded to treatment evaluated patients for pain, agitation, and PONV. Postoperative treatment consisted of fentanyl 1 microg/kg for pain and agitation and metoclopramide 0.15 mg/kg (maximum dose, 10 mg) for PONV. There were no significant differences between study groups with regard to age, weight, recovery time, agitation, or pain. Approximately 90% of the subjects found the ODT to taste good. No subject rejected the study medication, but the ondansetron-containing tablets were found to be less palatable than the placebo. The incidence of vomiting was significantly less in the ondansetron-medicated group.
Adenoidectomy↗
Rapid emergence does not explain agitation following sevoflurane anaesthesia in infants and children: a comparison with propofol.
BACKGROUND: Emergence agitation in children is frequently associated with the use of the new highly insoluble volatile anaesthetics. Rapid emergence has been cited as one of the possible causes. Propofol also permits rapid emergence from general anaesthesia but is not associated with agitation. METHODS: The emergence characteristics of children receiving sevoflurane and propofol anaesthesia were examined. After induction with sevoflurane, 53 children, aged 2-36 months, who were undergoing ambulatory surgery, were randomized to receive maintenance anaesthesia with either sevoflurane or propofol. Introperative analgesia with either 2 micro g x kg-1 of intravenous fentanyl or a caudal block with 0.25% bupivacaine was supplied according to surgical procedure. An observer blinded to anaesthetic technique recorded the time to achieve extubation and recovery and assessed emergence behaviour. Data were analysed using Wilcoxon scores, Kruskal-Wallis test, chi-square and multiple regression analysis. RESULTS: The results showed that the time to extubation and recovery were similar between the two study groups, but that emergence agitation was significantly higher in the sevoflurane group compared with the propofol group. No relationship between analgesic technique and agitation scores was found. CONCLUSIONS: Although both sevoflurane and propofol allow for rapid emergence from general anaesthesia, only sevoflurane is associated with a high incidence of emergence agitation in infants and young children. Rapid emergence does not fully explain this phenomena.
Anesthesia Recovery Period↗
Propofol or midazolam do not reduce the incidence of emergence agitation associated with desflurane anaesthesia in children undergoing adenotonsillectomy.
BACKGROUND: The aim of the study was to determine if concurrent use of short-acting sedatives would decrease the incidence of emergence agitation associated with desflurane while preserving rapid recovery. METHODS: Sixty-nine children, aged 2-9 years, who were undergoing adenotonsillectomy, were randomly assigned to three groups: (i) intravenous midazolam 0.1 mg.kg-1; (ii) propofol 2 mg.kg-1; and (iii) control. An observer blind to anaesthetic technique assessed emergence times and behaviour. Data were compared using chi-squared and ANOVA. RESULTS: Midazolam initially decreased the incidence of emergence agitation but, in the postanaesthesia care unit, significant agitation was seen in all three groups. Emergence and complete recovery were delayed in groups 1 and 2. CONCLUSIONS: The concurrent use of midazolam or propofol did not reduce the incidence of emergence agitation but did delay emergence and recovery. These agents are not recommended for reducing emergence agitation in children receiving desflurane.
Adenoidectomy↗
The effect of fentanyl on the emergence characteristics after desflurane or sevoflurane anesthesia in children.
UNLABELLED: Desflurane and sevoflurane anesthesia are associated with emergence agitation in children. In this study, we examined the effect of a single intraoperative dose of fentanyl on emergence characteristics in children undergoing adenoidectomy. One hundred children, 2-7 yr old, were randomly assigned to receive desflurane or sevoflurane for maintenance of general anesthesia after an inhaled induction with sevoflurane and a 2.5 microg/kg dose of fentanyl. An observer blind-ed to the anesthetic technique assessed the times to achieve emergence, extubation and recovery criteria, as well as emergence behaviors. The results showed a similar incidence of severe emergence agitation after general anesthesia with desflurane (24%) and sevoflurane (18%). Times to achieve extubation and postanesthesia care unit discharge criteria were shorter with desflurane than with sevoflurane. With this technique, desflurane allows for a more rapid emergence and recovery than sevoflurane. In children receiving desflurane or sevoflurane, the concurrent use of fentanyl in a dose of 2.5 microg/kg results in a small incidence of emergence agitation. IMPLICATIONS: The concurrent use of fentanyl in a dose of 2.5 microg/kg in children receiving desflurane or sevoflurane results in a low incidence of emergence agitation. Desflurane allows for a more rapid emergence and recovery than sevoflurane.
Analgesics, Opioid↗